Upper and Lower Gastrointestinal and Hepatobiliary surgery in adults - Guideline for Antimicrobial Prophylaxis

Publication: 14/08/2009  --
Last review: 01/02/2018  
Next review: 25/01/2021  
Clinical Guideline
CURRENT 
ID: 1761 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Antimicrobial Prophylaxis Guideline for Upper & Lower Gastrointestinal & Hepatobiliary Surgery in Adults

  1. Summary table of routine recommendations
  2. Background information
  3. Special antimicrobial prophylaxis recommendations

1. Summary table of routine recommendations

It is the responsibility of the surgical team to prescribe the prophylactic antibiotics, and the anaesthetist to give them within an hour of incision.

Procedure

Recommendation for antibiotic prophylaxis

Evidence level

Prophylaxis intended to reduce

NNT

Antimicrobial dose/route
< 1 hours before procedure or tourniquet application

Routine*

MRSA risk# or penicillin allergic*

Oesophageal surgery

Recommended

D 1,3

Wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Stomach & duodenal surgery

Recommended

A 1,3

Wound infection

5

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Gastric bypass surgery

Recommended

D 1,3

Wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Small intestinal surgery

Recommended

D1,3

Wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Appendicectomy

Highly recommended

A 1,3

Wound infection
Intra-abdominal abscess

11

103

Follow Appendicitis treatment guideline

Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV plus Appendicitis treatment guideline

Colorectal surgery

Highly recommended

A 1,3

Wound infection
Intra-abdominal sepsis

4

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV single dose

Bile duct surgery

Recommended

A 1,3

Wound infection

11

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Pancreatic surgery

Recommended

D1,3

Wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Liver surgery (excluding transplant) 

Recommended

D1,3

Wound infection

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Gall bladder (open or laparoscopic) in inpatients 

Recommended

A1,3

 

D1,3

Wound infection

11

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

Gall bladder laparoscopic day case (low risk)

Not recommended

A1,3

 

 

 

 

Hernia repair inguinal/femoral +/- mesh

Recommended with insertion of mesh or high risk patients only**

A1,3

 

 

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin  1g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV single dose

Hernia repair inguinal/femoral +/- mesh for strangulated or irreducible hernia repair

Recommended with insertion of mesh or high risk patients only**

A1,3

 

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin IV 2mg/kg IBW + Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg all single dose

Hernia repair (laparoscopic +/- mesh

Recommended with insertion of mesh or high risk patients only**

B1,3

 

 

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin  1g IV single dose

Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV single dose

Hernia repair (incisional +/- mesh)

Recommended with insertion of mesh or high risk patients only**

C1,3

 

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV single & Gentamicin IV 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV - all single dose

Open / laparoscopic surgery with mesh (eg gastric band or rectoplexy) 

NOT recommended except in high risk patients**

B1,3

 

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin IV 2mg/kg IBW +/- Metronidazole electronic Medicines Compendium information on Metronidazole 500mg IV - all single dose

Diagnostic endoscopic procedures

NOT recommended

D1,3

 

 

 

 

Therapeutic endoscopic procedures (ERCP & PEG)

See gastrointestinal endoscopy guideline

D1,3

 

 

 

 

Splenectomy

NOT recommended except in immunosupressed patients

D1,3

 

 

Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  1.2g IV single dose

##Teicoplanin electronic Medicines Compendium information on Teicoplanin  400mg IV & Gentamicin 2mg/kg IBW & Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg - all single dose

*redosing if procedure >4 hours long: Flucloxacillin electronic Medicines Compendium information on Flucloxacillin after 3 hours, Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav  after 4 hours, Metronidazole after 8 hours. Do not give another dose of GentamicinTeicoplanin electronic Medicines Compendium information on Teicoplanin or Vancomycin electronic Medicines Compendium information on Vancomycin .   
** High risk - conversion to laparotomy, pregnancy, immunosuppression, insertion of prosthetic devices.
## Teicoplanin electronic Medicines Compendium information on Teicoplanin takes 15 minutes to reconstitute, and is incompatible with Gentamicin. Flush with sodium chloride 0.9% between injections.

IDEAL BODY WEIGHT (IBW) dosing for Gentamicin

ADULT MALES (>16 yrs)

 

ADULT FEMALES (> 16 yrs)

Height

IBW  
(kg)

Gentamicin 
dose (mg)

ABW (use if less than IBW) (kg)

Height  

IBW (kg)

Gentamicin dose (mg)

ABW
(use if less
than IBW) (kg)

6’ 3” (1.9m) +

84.5

 

160

78 to 82

6’ 3” (1.9m) +

79.5

160

78 to 82

6’ 2” (1.88m)

82.2

6’ 2” (1.88m)

77.2

 

150

72 to 77

6’ 1” (1.85m)

79.9

6’ 1” (1.85m)

74.9

6’ (1.82m)

77.6

 

150

72 to 77

6’ (1.82m)

72.6

5’ 11” (1.8m)

75.3

5’ 11” (1.8m)

70.3

140

66 to 71

5’ 10” (1.78m)

73

5’ 10” (1.78m)

68

5’ 9” (1.75m)

70.7

 

140

66 to 71

5’ 9” (1.75m)

65.7

 

130

60 to 65

5’ 8” (1.72m)

68.4

5’ 8” (1.72m)

63.4

5’ 7” (1.7m)

66.1

5’ 7” (1.7m)

61.1

5’ 6” (1.67m)

63.8

130

60 to 65

5’ 6” (1.67m)

58.8

 

120

55 to 59

5’ 5” (1.65m)

61.5

5’ 5” (1.65m)

56.5

5’ 4” (1.62m)

59.2

 

120

55 to 59

5’ 4” (1.62m)

54.2

5’ 3” (1.6m)

56.9

5’ 3” (1.6m)

51.9

100

49 to 54

5’ 2” (1.57m)

54.6

5’ 2” (1.57m)

49.6

5’ 1” (1.55m)

52.3

100

49 to 54

5’ 1” (1.55m)

47.3

90

43 to 48

5’ (1.52m) or less

50

5’ (1.52m) or less

45

MRSA Risk Factors#
Patients within these categories are considered at increased risk of MRSA infection:

  1. Known previous infection with MRSA or colonisation at any time.
  2. Resident of a long term care facility (nursing home, residential home or any other long term residential facility) without a negative MRSA screening result.
  3. Any history of inpatient hospital stay within the previous 6 months without a negative MRSA screening result

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2. Background information

The aim of antimicrobial prophylaxis when used in gastrointestinal, hepatobiliary or abdominal surgery is a reduction in surgical site infection (SSI) - a potentially debilitating and occasionally life-threatening complication.

The continued presence of meticillin-resistant Staphylococcus aureus (MRSA) in the Trust and the ongoing problem of Clostridium difficile infection have prompted a review of surgical prophylaxis. It is appropriate to use a single pre-operative dose of prophylaxis in most situations to reduce the risks related to antimicrobial use while gaining maximum benefit from prophylaxis (NICE, (Leaper, 2008 #74) & SIGN). There is increasing evidence linking the use of cephalosporins even with a three dose prophylaxis regime to increased C. difficile infection 5

These guidelines should be applicable to the majority of patients. Where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

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3. Special antimicrobial prophylaxis recommendations

Evidence for the efficacy of prophylaxis, A; choice of agents, D

Conversion of prophylaxis to treatment
If a course of treatment is started as a result of operative findings it is important to document the change from prophylaxis to treatment, the indication and planned duration of therapy.

Upper gastrointestinal tract surgery3

Stomach and duodenal surgery
Four randomised controlled trials were identified that compared the use of antibiotic prophylaxis with placebo or no antibiotic in stomach and duodenal surgery. Three reported wound infection outcomes for patients and one reported wound infections as a proportion of the overall number of wounds. One RCT included patients undergoing general surgery and randomised them to either cefaloridine (376 wounds) or no antibiotic (386 wounds). [Evidence level (EL) = A] There was one wound infection in those undergoing gastric surgery with antibiotic prophylaxis (33 wounds) and six infections in the gastric surgery patients who did not receive antibiotics (30 wounds). This difference was not statistically significant (OR 0.13, 95% CI 0.01 to 1.11).

One RCT included 83 patients undergoing surgery for high-risk gastroduodenal disease who were divided into two treatment arms, one of which received two doses of cefaloridine, the other no antibiotic. [EL = A] A further low-risk treatment arm was not considered here. No wound infections were found in the cefaloridine group (n = 41 patients) compared with 11 in the no antibiotic group (n = 42 patients). This difference was statistically significant (OR 0.03, 95% CI 0.00 to 0.58). One RCT included 39 patients undergoing gastroduodenal surgery with a high postoperative risk. [EL = A] One infection was found in the cefamandole group (n = 19 patients) and seven were reported in the placebo group (n = 20 patients). This difference was statistically significant (OR 0.10, 95% CI 0.01 to 0.94). One RCT included 68 consecutive patients undergoing elective surgery of the gastrointestinal tract. [EL = A] There were no infections in the antibiotic group (n = 32 patients), but 11 in the placebo group (n = 36 patients). This difference was statistically significant (OR 0.03, 95% CI 0.00 to 0.61). A meta-analysis of the three trials that reported wound infections in patients rather than as a proportion of all wounds found an overall statistically significant protective effect of antibiotics compared with placebo or no antibiotics (OR 0.05, 95% CI 0.01 to 0.22).

Coliforms were the predominant cause of wound infections in one study, while mixed organisms were reported from another. Cephalosporins were used in each of these trials with no additional anti-anaerobic coverage.

Hepatobiliary surgery3

Bile duct surgery3
One systematic review was identified. Forty-two RCTs of biliary tract operations comparing the effects of antibiotic prophylaxis with ‘control’ for wound infection were pooled in a meta-analysis in a systematic review. [EL = A] Biliary tract surgery was defined as all operations on the gallbladder and/or common bile duct, including cholecystectomy, exploration of the common bile duct and choledochoenterostomy. Control interventions varied (povidone-iodine, placebo, topical antibiotic, prophylaxis with/ without additional antibiotic, etc.). All trials were conducted between 1965 and 1988 and reported wound infection as an outcome. Although there was a range of definitions of wound infection, the most common was ‘discharge of pus’ from the wound. Details of the number of participants were not given although studies of less than ten participants were excluded. Overall, there were fewer wound infections in the antibiotic prophylaxis group compared with the ‘control’ group. This difference was statistically significant (OR 0.30, 95% CI 0.23 to 0.38). Meta-analysis of three trials comparing the effect of antibiotic prophylaxis versus placebo on SSI incidence in upper gastrointestinal tract surgery

Laparoscopic gallbladder surgery3
One systematic review and two RCTs were identified. One relevant systematic review and two more recently published RCTs from India and Taiwan were included. The systematic review (six RCTs, n = 974 patients) compared the effect of antibiotic prophylaxis with that of placebo on wound infection in patients undergoing low-risk laparoscopic cholecystectomy. [EL = A] The pooled OR was 0.71, 95% CI 0.32 to 1.60, suggesting that there was no difference in wound infection incidence following antibiotic prophylaxis (12/567) or placebo administration (12/407) in laparoscopic cholecystectomy. One trial included 93 patients of ASA score 1 and 2 diagnosed as having gall stone disease undergoing laparoscopic cholecystectomy. [EL = A] Forty patients were randomised to receive1.5 g cefuroxime in 100 ml sodium chloride 0.9% at anaesthesia induction while 53 patients received normal saline similarly administered. There were three postoperative wound infections – one in the antibiotic group and two in the placebo group. This finding was not statistically significant
(OR 0.65, 95% CI 0.06 to 7.47). One trial included 277 patients with symptomatic gallbladder stones or polyps disease with or without acute cholestasis who were candidates for laparoscopic cholecystectomy. [EL = A] One hundred and forty-one patients were randomised to receive 1 g cefazolin given at anaesthetic induction and 136 received 10 ml sodium chloride 0.9% solution similarly. There were two infections, both of which occurred in the placebo group. This finding was not statistically significant (OR 0.19, 95% CI 0.01 to 4.00). A meta-analysis of all participants’ wound infection outcomes was performed that yielded a similar non-statistically significant result (OR 0.63, 95% CI 0.30 to 1.32).  

Lower gastrointestinal tract surgery3
Appendicectomy
One systematic review was identified.
A Cochrane systematic review was identified that investigated the use of antibiotics compared with placebo or no prophylaxis in patients undergoing appendicectomy. [EL = A] Both adults and children were included.
The outcomes were described according to the nature of the appendix – simple or complicated – or ‘appendicitis’ when not specified. Seventy-one studies were included in total, all of which reported wound infection as an outcome. Meta-analyses for both clinical and pathoanatomical descriptions of appendicitis reported statistically significantly fewer wound infections associated with the use of systemic antibiotics
compared with placebo (Peto OR 0.33, 95% CI 0.29 to 0.38 and Peto OR 0.32, 95% CI 0.22 to 0.47, respectively). Single or multiple antibiotics given as a single dose preoperatively resulted in statistically significantly fewer wound infections than preoperative placebo prophylaxis (overall Peto OR 0.34, 95% CI 0.25 to 0.45 and overall Peto OR 0.14, 95% CI 0.05 to 0.39, respectively). Meta-analysis of three trials comparing the effect of antibiotic prophylaxis versus placebo on SSI incidence in hepatobiliary surgery

Colorectal surgery
A systematic review was identified that compared antibiotic prophylaxis with no antibiotic administration in colorectal surgery. [EL = A]. Four trials published since 1984 were included that compared patients receiving antibiotic prophylaxis for colorectal surgery with a control group not given antibiotics. The antibiotics used prophylactically in these four trials were Gentamicin plus Metronidazole electronic Medicines Compendium information on Metronidazole , Metronidazole alone or Metronidazole electronic Medicines Compendium information on Metronidazole plus ampicillin, mezlocillin plus oxacillin, and cefoxitin. The results from the individual studies showed consistently that the wound infection rate was much lower in the antibiotic groups than that in the control groups (12.9% versus 40.2%; OR 0.24, 95% CI 0.13 to 0.43).

Hernia repair3
One systematic review and one RCT were identified. A recently updated Cochrane systematic review (12 RCTs, n = 6705 participants) was identified that evaluated antibiotic prophylaxis compared with placebo for prevention of wound infection in hernia repair. [EL = A]. Six trials (n = 2436 participants) used prosthetic material for hernia repair (hernioplasty) whereas the remaining studies (n = 4269 participants) did not (herniorrhaphy). For hernioplasty, there were 17 wound infections among the patients who received prophylaxis (n = 1196 participants) compared with 37 in those receiving placebo (n = 1240 participants). This difference in wound infection incidence was statistically significant (OR 0.48, 95% CI 0.27 to 0.85). For herniorrhaphy, there were 103 wound infections among the patients who received prophylaxis (n = 2932 participants) compared with 66 in those receiving placebo (n = 1337 participants). This difference in wound infection incidence did not quite reach statistical significance. Overall, for both hernia repair methods, there were fewer wound infections among the participants who received prophylaxis (120/4128 participants) compared with those receiving placebo (103/2577 participants). This was a statistically significant finding (OR 0.64, 95% CI 0.48 to 0.85).
A further RCT that was not referred to in the Cochrane review was also identified that compared the effect on wound infection of a single dose of amoxicillin and clavulanic acid (Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav ) with that of normal saline in elective open repair of inguinal hernia using mesh. [EL = A]. There were five reports of wound infection in the antibiotic group (n = 190 participants) compared with nine in the placebo group (n = 189 participants). This was not a statistically significant difference (OR 0.54, 95% CI 0.18 to 1.64). Pooling the results of this RCT with the review of hernioplasty demonstrated a statistically significant difference between the two groups (OR 0.49, 95% CI 0.30 to 0.81).

Infection Control and Hospital Epidemiology November 2008, vol. 29, no. 11 Australian Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections: Annual Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007

Evidence levels
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT Consensus (no national guidelines exist, guidelines from different learned bodies contradict each other, or no evidence exists)

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Provenance

Record: 1761
Objective:
Clinical condition:

Gastrointestinal pathology

Target patient group: Adults
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

  1. SIGN. Antibiotic Prophylaxis in Surgery. Scottish Intercollegiate Guideline Network Publication Number 104. Edinburgh; 2008.
  2. Gemmell CG, Edwards DI, Fraise AP, Gould FK, Ridgway GL, Warren RE, et al. Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the UK. 2006. p. 589-608.
  3. Leaper D, Collier M, Evans D, Farrington M, Gibbs E, Gould K, et al. Surgical site infection: prevention and treatment of surgical site infection. In: health NCcfwac, editor.: Royal College of Obstetrics and Gynaecology, Press; 2008. (NICE)
  4. Infection Control and Hospital Epidemiology November 2008, vol. 29, no. 11 Australian Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections: Annual Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007
  5. Fenton P et al. Journal Hospital Infection 68, (4), April 2008, Pages 376-37 Clostridium infection following hip surgery.

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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